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Neurology (Expert Forum)
Re: 9 Month Migraine 24 Hours/Day
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Re: 9 Month Migraine 24 Hours/Day
by CCF Neuro[P] MD RPS, Jan 01, 1995 12:00AM
Posted By CCF Neuro[P] MD, RPS on January 30, 1999 at 11:17:36:
In Reply to: 9 Month Migraine 24 Hours/Day posted by Chris on January 27, 1999 at 13:06:57:
My wife has similar situation to an archived posting about a long term headache following a lumbar puncture ad blood patches, in her case a myelogram. However, her symptom is a migraine with nausea, photophobia and other typical migraine symptoms 24 hours per day since March 18, 1998. The neurologists have prescribed various medication protocals, including bilateral occipital nerve blocks and hospitalization for thorazine and DHE treatments, without any relief. Now she is undergoing withdrawal from her current medicines in a pain clinic while undergoing pain managment training. First, will this migraine ever go away and any guess at how long it will take?. What was the outcome of the archived posting "Can a Blood Patch Cause a Headache" (1997) (may not be the exact title). I assume from the archived posting that morphine was helping this patient, but in my wife's case morphine only "took the edge off" same for dilaudid. She only took them for a short time and was most recently on Duragesic patch, serzone and depakote. She is more than happy to get off the medications even with the pain. Her migraine is located primarily in the base of her head and radiating up the back of the head. The pain is a steady pressure like pain not throbbing. Activity does tend to make it worse, but it is not positional. Over the past few weeks the pain became more intense and covered more of her head. The Duragesic (100ug/hr)patch took the edge off in the beginning, but was not offering any relief before she was admitted to the pain clinic. Her MRI, CT and Cisternogram should nothing. CSF pressure was 11, considered by the doctor to be within the normal range. Her current course of treatment is a two week withdrawl period, pain managment training and start sansirt (sansert?). Any suggestions? I can give you a more detailed case history or her doctors' phone numbers. Thank you.
Dear Chris:
Sorry to hear about your wife. An LP type headache is due to the procedure and the continued leak of the CSF from the puncture site. A blood patch is used to seal up the leaky site (coagulation of the opening) and when this occurs, the headache resolves. The blood patch does not cause the headache, but it relieves it. The migraines are from something else, sounds like just terrible migraines. I would agree with the pain clinic doctors in stopping the other narcotic medications. Most of us believe that narcotics really don't help the pain of migraines nor do they have an effect of resolving the underlying physiological etiology of migraine. All narcotics do is blunt the pain. I assume that she has tried all the usual medications such as the new tryptans (imitrex, etc.). Anyway, the way we start out is to begin a medication with serotonin activity such as elavil. We will increase the dose until effect or until we reach about 5 mg/kg/day. If this or imitrex for breakthrough headaches do not help then we progress to the calcium channel blockers (another subtype of migraine is a calcium channel defect). If we do not see any benefit from this then we would try valproate. If this doesn't have an effect then the search for atypical migraine medications such as indomethacin. We have also seen some patients respond to high dose riboflavin. But each headache clinic has their own protocol. But you will notice that we stay away from the narcotic medications. I wish your wife well.
Sincerely,
CCF Neuro[P] MD
In Reply to: 9 Month Migraine 24 Hours/Day posted by Chris on January 27, 1999 at 13:06:57:
My wife has similar situation to an archived posting about a long term headache following a lumbar puncture ad blood patches, in her case a myelogram. However, her symptom is a migraine with nausea, photophobia and other typical migraine symptoms 24 hours per day since March 18, 1998. The neurologists have prescribed various medication protocals, including bilateral occipital nerve blocks and hospitalization for thorazine and DHE treatments, without any relief. Now she is undergoing withdrawal from her current medicines in a pain clinic while undergoing pain managment training. First, will this migraine ever go away and any guess at how long it will take?. What was the outcome of the archived posting "Can a Blood Patch Cause a Headache" (1997) (may not be the exact title). I assume from the archived posting that morphine was helping this patient, but in my wife's case morphine only "took the edge off" same for dilaudid. She only took them for a short time and was most recently on Duragesic patch, serzone and depakote. She is more than happy to get off the medications even with the pain. Her migraine is located primarily in the base of her head and radiating up the back of the head. The pain is a steady pressure like pain not throbbing. Activity does tend to make it worse, but it is not positional. Over the past few weeks the pain became more intense and covered more of her head. The Duragesic (100ug/hr)patch took the edge off in the beginning, but was not offering any relief before she was admitted to the pain clinic. Her MRI, CT and Cisternogram should nothing. CSF pressure was 11, considered by the doctor to be within the normal range. Her current course of treatment is a two week withdrawl period, pain managment training and start sansirt (sansert?). Any suggestions? I can give you a more detailed case history or her doctors' phone numbers. Thank you.
Dear Chris:
Sorry to hear about your wife. An LP type headache is due to the procedure and the continued leak of the CSF from the puncture site. A blood patch is used to seal up the leaky site (coagulation of the opening) and when this occurs, the headache resolves. The blood patch does not cause the headache, but it relieves it. The migraines are from something else, sounds like just terrible migraines. I would agree with the pain clinic doctors in stopping the other narcotic medications. Most of us believe that narcotics really don't help the pain of migraines nor do they have an effect of resolving the underlying physiological etiology of migraine. All narcotics do is blunt the pain. I assume that she has tried all the usual medications such as the new tryptans (imitrex, etc.). Anyway, the way we start out is to begin a medication with serotonin activity such as elavil. We will increase the dose until effect or until we reach about 5 mg/kg/day. If this or imitrex for breakthrough headaches do not help then we progress to the calcium channel blockers (another subtype of migraine is a calcium channel defect). If we do not see any benefit from this then we would try valproate. If this doesn't have an effect then the search for atypical migraine medications such as indomethacin. We have also seen some patients respond to high dose riboflavin. But each headache clinic has their own protocol. But you will notice that we stay away from the narcotic medications. I wish your wife well.
Sincerely,
CCF Neuro[P] MD
